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Case Presentations in Heart Failure
Ivor L Gerber
Cardiologist
Auckland Heart Group
Auckland City Hospital
Case 1
82 year old woman
Longstanding hypertension
Treatment for UTI
Otherwise well
Increasing shortness of breath
Leg swelling
Palpitations
Clinical exam Irregular rhythm, 110bpm
BP 160/90mmHg
Mild pitting oedema. No murmur. JVP +4cm. Bibasal crackles
ECG Atrial fibrillation, LVH.
Troponin Normal
N-BNP 120
CXR Mild cardiomegaly
Mild interstitial oedema
Diagnosis – “Heart failure”
Diagnosis – “Heart failure”
Clinical assessment
Supported by investigations so far
What is the likely cause?
Common things occur commonly
Hypertension
LVH, LV diastolic dysfunction, left atrial dilatation.
Coronary artery disease
LV systolic / diastolic dysfunction
Valve disease
LV systolic / diastolic impairment.
Precipitating factors
Recent UTI
Atrial fibrillation
Check thyroid function
What additional investigation(s) are needed?
Echocardiogram
LV size and systolic function - often normal LVEF
LVH. LV diastolic function.
LA size
Valves
Right heart
What additional investigation(s) are needed?
Echocardiogram
LV size and systolic function - often normal LVEF
LVH. LV diastolic function.
LA size
Valves
Right heart
24 hour holter monitor
After rate control
Exercise test
Consider after acute factors managed
Treatment
General
Diuresis
Rate control of the atrial fibrillation
Ensure the UTI is controlled
Optimise blood pressure
Specific
Depend on other results
Rate vs rhythm control (LA size)
Possible coronary artery disease
Case 2
24 year old man
No past history of note
Physical job
Non-smoker
Minimal alcohol
Tires easily, short of breath on exertion
Clinical exam
Regular rhythm 110bpm
BP 95/60 mmHg
Multiple murmurs
No pitting oedema. JVP angle of jaw. Clear chest
ECG
Sinus tachycardia, LVH
N-BNP
1120
CXR
Moderate cardiomegaly
Pulmonary oedema
Diagnosis
Heart failure
What is the likely cause?
Common things occur commonly
Valve disease – LV and/or RV impairment.
Hypertension – LV diastolic dysfunction +/- atrial fibrillation
Coronary artery disease – LV systolic/diastolic dysfunction
What additional investigation(s) are needed?Echocardiogram
TreatmentGeneral
Specific
Treatment
General
Diuresis
ACE inhibitor / ARB
Beta blocker
Specific
Valve replacement
Heart Failure
The diagnosis heralds the beginning, not the
end, of the medical journey
Clinical diagnosis supported by investigations
Specific management depending on the cause
High mortality, especially if not assessed and
managed properly
Diagnosis
“Heart failure”
What is the likely cause?
Always consider underlying cause and precipitating factors
What investigation(s) are needed?
Confirm diagnosis
Mechanism – guides management
Determine severity / prognosis
Treatment